Fresh off his second tour of Ebola-stricken West Africa, the head of the Centers for Disease Control said Monday that despite signs of “real momentum and real progress” in the region, there are sobering challenges ahead and the world will remain at risk until cases are brought down to zero.

“It’s going to be a long hard fight, but I am hopeful that we are going to see continued progress,” said CDC Director Dr. Thomas Frieden, MD, MPH. “The challenge is not to let up, not to be complacent and to really double down.”

Dr. Frieden’s assessment comes on the heels of another high-profile tour of the outbreak region, that of United Nations (UN) Secretary-General Ban Ki-moon, who issued a similar warning against complacency in the Ebola battle, which has seen some progress, especially in parts of Liberia.

The World Health Organization (WHO) said today that 19,431 infections have now been reported, including 7,565 deaths. Sierra Leone has had the highest number of cases since early December, which is at 9,004 as of Dec 21. However, Liberia has the highest number of deaths, of which 3,376 have been reported as of Dec 18.

Country-specific observations, lessons

At a media telebriefing on Monday, Dr. Frieden spoke of a mixed picture of what he observed in Guinea, from an encouraging drop in Ebola cases in a rural areas where response teams had originally faced community resistance, to deep worries about a lack of isolation beds and a “troubling spread” of Ebola in Conakry, the country’s capital. He said a lack of beds raises the risk of people sick with Ebola remaining in the community, the key factor that fuels chains of transmission.

Regarding Sierra Leone, Dr. Frieden said “extensive challenges” remain throughout much of the country, noting that high levels of disease in the capital, Freetown, are a major concern. “Sierra Leone has by far the largest number of cases of the three countries at this point and is in a rapid scale-up phase,” he said. In describing the Ebola battle in Sierra Leone, he said the situation is more like trying to manage many brush fires than a forest fire. “Each of those brush fires needs to be put out by rapid and sensitive outreach,” he said.

Map showing the distribution of the Ebola outbreak in West Africa as of December 17, 2014 (Source: CDC).

On the positive side in Sierra Leone, safe burial teams have made some headway, using an approach that is culturally sensitive and involves family, he added. Despite Sierra Leone’s surge in cases over the past several weeks, the country has an impressive and well-organized command center staffed by British officials, the country’s health ministry, and other partners, he said.

Liberia presently has the upper hand over the disease, “but that’s as of today,” Frieden Dr. said. He stated that the situation can change quickly and that complacency is another challenge the outbreak region faces in the weeks ahead. As the number of cases has fallen, he said, health care workers have been “relaxing their grip”, by, for example, not wearing protective clothing or ignoring the possibility of Ebola infection when treating patients for other ailments. He described how a nurse in Guinea acquired the Ebola virus from a patient — and survived — after she started an intravenous line on him without wearing any gloves.

A particularly worrying indication he saw in Monrovia was a belief by some that the urban Ebola treatment centers aren’t safe, driving certain individuals to seek care in other districts, which can spread the disease and complicate contact tracing as people hire taxis or use other transportation to carry sick family members out of the capital. On the positive side, a new cemetery is opening in Monrovia, which should ease the need to cremate Ebola victims, a practice that goes against cultural practices and that health officials think may have led to clandestine burials, which are known to spread the disease.

Dr. Frieden shared several examples of outbreak responders transforming grim situations into hopeful ones, such as a social worker in Sierra Leone who lost both of his parents to Ebola but is now caring for children orphaned by the disease, and of now-idled gravediggers in Liberia who have started making furniture for Ebola survivors. He said health officials in all three of the countries are eager to learn how to manage the disease themselves and that he’s encouraged by support and epidemiology expertise coming from the African Union.

Preparing for the fight ahead

The next phase of the response is to break the cycle of exponential growth, trace each chain of transmission, and strengthen health systems in areas that are free of Ebola, Dr. Frieden said. “The next phase is in many ways harder — it’s tracing every single case to break every single chain of transmission including in highly mobile urban areas and that’s going to be challenging,” he said. “The problem is there are clusters all over and new ones popping up all the time.”

He stressed that the response to the outbreak must not let up until the number of cases drops to zero; with a disease like Ebola, even one case in the community is enough to reignite an outbreak — in fact, the 2014 epidemic has been traced back to a single two-year-old child. “… [G]oing forward, the challenge is to get to zero,” Dr. Frieden said. Until then, “we in the U.S. will not be safe from other potential imported cases … [and] we can’t be sure that the disease won’t spread to other countries and potentially develop more challenging patterns,” he warned.

He said it’s impossible to project when the outbreak will be extinguished but that Congress’s recent passage of President Obama’s Ebola response spending request in the overall budget legislation will help the CDC do more to help the countries track cases and respond quickly to new infections. The funding, he said, “allows us to see the possibility of an end to this epidemic more clearly.”

Dr. Frieden noted that experiences battling Ebola in each country are yielding important lessons for the others. For example, Liberia has had success with the RITE (Rapid Isolation and Treatment of Ebola) strategy for addressing hot spots, an approach that could be implemented in Guinea and Sierra Leone. Meanwhile, sensitivity on the part of burial teams in Sierra Leone can be employed elsewhere to support safe burial goals. He added that all three countries, but especially Guinea, need major improvements in their infection control capacities.

Other Ebola news

British researchers from Cambridge University and two other institutions said in a commentary in the Dec 21 early online edition of Lancet Global Health that International Monetary Fund (IMF) economic policy reforms over the past years may have undermined the ability of Guinea, Liberia, and Sierra Leone to respond to outbreaks and other emergencies, such as the Ebola outbreak. In reviewing IMF lending programs between 1990 and 2014, they said reforms reduced government spending, included public sector wage caps that could have impacted the ability to hire and pay key health workers, and pushed for decentralized healthcare systems, which could have made it difficult to mount a coordinated response. In a statement today, the IMF said the commentary had several inaccuracies and that health spending as a percent of gross domestic product increased in all three countries from 2010 to 2013. It added that World Bank data suggest health outcomes have improved in the three countries and said IMF programs have not had any limits on the wage bill from 2000 through 2014.

An experimental vaccine that could be a first line defense against Ebola showed “promising results” in its first major test, scientists said this week. A Phase 1 clinical trial conducted in Africa found that the vaccine, called RV 247, is safe and prompts an effective immune response in patients. This is the first time such findings have been reported in an African population. However, more research is needed to see if it still offers protection months down the line, the authors reported in The Lancet medical journal.

In a separate report also published in The Lancet, a team of German doctors described the successful treatment of an Ebola patient with an experimental heart medication called FX06. The patient, a 38-year-old doctor from Uganda, contracted Ebola while working in Lakka, Sierra Leone in September, and was flown to Frankfurt University Hospital in Germany for treatment. By the time the patient arrived at the hospital, his organs had already started to fail, and within 72 hours he had developed hemorrhaging — a sign that the disease was progressing. In addition to intensive supportive care, including dialysis, IV fluids and antibiotics, doctors also gave him a 3-day course of FX06, an experimental drug designed to treat vascular leakage, or loss of fluid from the blood vessels, to prevent further damage in cardiac patients after a heart attack. The drug works by sealing the walls of blood vessels, which are thinned out when the Ebola virus begins to attack the body. After receiving the drug, the patient showed “marked improvement in vascular and respiratory function,” the Lancet article says. Thirty days after he first started showing symptoms, doctors determined he was Ebola free and discharged him from the hospital. However, the researchers cautioned that it’s still unclear what role FX06 played in the patient’s recovery, or whether the quality supportive care he received was the main factor that helped him survive. They concluded by calling for rapid follow-up research to study the drug’s potential as an Ebola treatment.

A study on the impact of Sierra Leone’s Ebola outbreak on its regular health facilities revealed that the event dropped the number of hospital admissions for non-Ebola conditions by 70% and reduced the number of major surgeries by 50%. The study, by Swedish and Norwegian researchers and their partners in Sierra Leone, appeared Dec 19 in Public Library of Science (PLoS) Currents Outbreaks. The team, which based its findings on weekly data from 40 facilities between Jan 6 and Oct 12 of 2014, said the dramatic decline in admissions is likely an underestimation and that “reestablishing such care is urgent and must be a priority.”